A post I wrote yesterday touched a nerve with many ghosts of the night. Many suggested I was failing my duties as a physician for leaving the bedside of a patient to gather the support team for resuscitation efforts, suggesting instead I should have started bagging the patient myself, while I yell outside for help. Or, (as I suggested a once in a lifetime experience)to pull the code blue chord myself.
So I took a little survey on my rounds today. I rounded on 15 patients today. Excluding my ICU patients, I counted the number of Ambu bags that were stocked in my other 12 patient rooms . I searched high and low. Room after room. I opened closets. I opened drawers. I searched every where. Guess how many I found.
Zero. Zip. Nadda. Zilch. Nul.
I talked with a respiratory therapist and asked him where they are. He said they are stocked in one supply closet on every floor. The only places they are stocked in every room are the ICU and the ED.
One reader suggested this was unacceptable hospital policy. That I should contact the "Vice President of Patient Care" to change such as dastardly policy as it represented a patient safety issue. I would suggest this reader has minimal exposure to inpatient medicine and the economics of inpatient medicine.
Stocking an Ambu bag in every room ain't gonna happen. It ain't gonna happen in just about every hospital in this country, except the really rich ones. It is not reasonable, nor rational to have a fully stocked ICU in every patient room of a hospital, in spite of what some wish to believe. I might also add that Happy's Hospital is a level one trauma center, cardiac center, cancer center, neurosurgical center, whatever center. You can get everything at Happy's hospital. I do not work at a rinky dink hospital in the middle of no where with one ventilator and a part time physician that only works M-F from 8am to noon. We have it all, and we don't stock Ambu bags. That is a reality. Because it is the right reality.
It's hard to bag someone without a bag. I'm ready to accept y'all apologies at any time. Those angry at me for not bagging the patient, have been lead astray by forces not familiar with inpatient medicine. If you want the truth on inpatient medicine, stick with me. If you want outsiders opinions on inpatient medicine, go somewhere else.
As for the nursing staff, Happy's nursing team did an excellent job that day saving that patient's life. I take great pleasure in knowing that many of them excel in their duties and responsibilities on their floor duties as a nurse, a job harder than just about every other field of medicine. I have great confidence in many of them for the expertise in nursing related patient care issues and I would trust most of them with my life.
Saturday, June 27, 2009
Is It Reasonable To Stock Every Hospital Room With Emergency Rescusitation Supplies
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37 Outbursts:
"Every patient room should have an ambu bag hanging up near the patient's head of the bed. You've been a doctor for 6 years and haven't figured this out? This is the same whether you're in ER or ICU or med/surg. I don't work at your hospital, but I guarantee they're there. Check it out on your rounds."
See, Happy? It was there. Nurse K herself GUARANTEED it. Look again. I'm sure it's there.
Well, every hospital I've worked at or did clinical rotations at had ambu bags in every room, excluding psych. People code all over the hospital, not just in ICU or the ER. This website says they cost about $26 each.
I've done some stuff in my ER to change protocols that I found to be WTFy (including one fairly lengthy and frustrating endeavor regarding how airways are managed), and a lot of the time the reason I was given why the protocol wasn't already the way I wanted was because it simply hadn't been addressed. Why don't we have propofol in the Pyxis? Well, no one ever asked for it. Why aren't we using rocuronium in the ED? Well, because we don't stock it. Why don't we stock it? Because no one has asked for it to be stocked.
So, basically, you did the right thing. You checked it out, no ambu bags. I would assume that you'd (as well as probably everyone else) prefer there to be an ambu in each room. You're assuming such a policy would not be approved due to cost, but have you asked? No. I thought the rocuronium/propofol thing was a cost issue as well, but it wasn't. Don't assume, Happy.
I'd still bring it up. An email to whoever is the boss of the nursing managers would not kill you. On my little policy endeavors, I was able to delegate things to others. Maybe your part will be just to bring it up as an issue and ask that this be changed.
Every patient room should have an ambu bag hanging up near the patient's head of the bed. You've been a doctor for 6 years and haven't figured this out? This is the same whether you're in ER or ICU or med/surg. I don't work at your hospital, but I guarantee they're there. Check it out on your rounds.
--Nurse Know-it-all
No doubt the mob from the other thread will be here shortly to call you a liar, Dr. Happy.
Oh, and an ambu bag isn't a fully-stocked ICU. A code cart can have all the necessary medications, airway crap, and defibrillator. While someone gets the code cart, you and an aide or nurse can do BLS, which is the current AHA guideline emphasis. If you're futzing around looking for ambu bags (do you think the float staff, the aides, or the critical care response team know where these are on every floor? Not.), you're wasting valuable time. This was the main type of argument I used on my airway policy proposal. Time is brain.
Oh, so an ambu bag is only $26.59. Every hospital room in America should have one. Anything else every hospital room should have, Nurse Know-it-all? Should we just outfit them all to be equivalent to ER rooms?
There's a reason it's more expensive to have a patient in the ER or the ICU than in other rooms.
$26 for the A and the B of the ABCs to be implemented immediately. Too much to ask? Guess what, you can charge the patient for the use of the bag too in the event they stop breathing. We most certainly do. I'd rather my insurance be billed $50 for a bag than thousands for rehab for an anoxic brain injury while my nurse dug through cabinets looking for the single ambu bag on the floor screaming "where is it, where is it???" while a team of well-trained professionals stood around tapping their feet coming up with cool one-liners.
As a former inpatient med/surgy nurse, we were expected to check our rooms each shift for presence of an ambu bag.
Let's face it, Dr. Happy. No matter what you post, no matter what you do, Nurse know-it-all will find something to pick apart about it. It seems she just can't leave you alone. Must be that PE she's got.
I don't see anything in your post about a desperate search for a bag, an assessment of a pulse, a "hey, wake up!" or yelling out for someone to get a bag, so I will not apologize. I only see things written about you watching a blue patient not breathing for 30 seconds before, a couple of mentions how the narc was "nurse-administered", a calm request to intervene in a life-threatening situation, and a description of all the stuff you wish you would have said to look cool for the nursing staff. On my blog, you go so far as to suggest that it would be wrong to intervene in saving his life before leaving.
Certainly, there is a system problem in addition to your arrogance, but you dismiss the system problem of basic BLS equipment as something that shouldn't be dealt with. Maybe we should remove those pesky suction canisters too, eh? Too expensive to clear the airway?
Regardless of whether or not there are ambu bags readily available (which, I have to say, is one of the less-brilliant ideas I've encountered), is there anyone else out there that would have just started giving rescue breaths? I mean, yeah it's gross, but....
Anyway, just my 2 cents. :)
See happy, Nurse K is still jonesing for your penis.
Happy could have and should have yelled for assistance. He could have and should have reached over and attempted to rouse the patient. He could have and should have pulled the cord so conveniently located right next to the barely breathing patient. In the event it was necessary he could have and should have started CPR as the rest of the team gathered 'round. What he should not have done was saunter over to the nurse's station (however closeby) and asked the nurses what they thought he should do.
It's not rocket science. It's not even brain surgery.
Really glad the patient was saved. You're still coming across as a self-righteous, self-important, arrogant ass. By the way, at my 500 bed Level One Trauma Center University Teaching Hospital, prior to each and every shift we were expected to do a supply check that included an ambu-bag (among other supplies) being located at the head of each and every patient bed as well as on each of the four crash carts located on our floor. This wasn't ICU, it was oncology.
No Ambu bags in each room of any hospital that I go to either.
Does anybody actually take Nurse K seriously anymore? She's a caricature of an actual nurse.
Every hospital I have been in in the Seattle area has either a BVM or a pocket mask at the head of the bead in a wall bracket. I am surprised that this isn't the case where you work. At the hospital or in the community ventilation/CPR is the first step before the carvery arrives.
Again, all anyone wants is for you to acknowledge your mistakes and learn from them. We're still waiting. Taking your words at face value, your priorities are counting [lack of] respirations for an extended period of time despite noting that the patient is blue and presumably not alert ---- > being a jerk to nursing staff (although you think your manner of speaking is complimentary which is hilarious) ----> giving narcan. Your priorities should have been trying to awaken the blue patient while you called for help, bagged him while checking a pulse, and then doing other things like narcan. The only positive thing is that you tried to figure out where the ambu bags were today, but failed at an opportunity to correct the underlying problem of them not being readily accessible, writing off the fix as too expensive without any real data to support that. Believe it or not, a hospitalist like you wields more power than you may think.
This is a great illustration of how things don't progress in health care. Someone identifies a problem (no ambu bags readily accessible), identifies a possible solution (ambu bags in each room), learns that other hospitals do this, yet fails to do anything about it, making the mistake/problem continue unchecked. Same goes for your personal handling of the patient. You can't even ID a problem here other than lack of ambu bags.
Again, we're waiting.
I can see how it might be irritating to have a nursing student or an LPN tell you how to do your job, but there were plenty of doctors who weighed in. I believe that many people found your attitude offensive. It sounded like you stood there over the guy, bemusedly noting the particular blue hue of his skin and reminiscing about some jackball attending in your past.
Did it occur to you to grab his shoulders and say,"Arnie, Arnie, are you OK?" Maybe you made the whole story up, which I guess would explain the odd miscues in your stated response and your explanation of same which really doesn't say much of anything 'cause the Ambu bag thing is a red herring at this point.
Anybody notice the irony of Nurse Know It All's first sentence?
The hospital I work at has ambu bags in every room. We're not a trauma center at all. That's kind of sad that your hospital doesn't make that a priority. Every hospital I've been to has them hanging in the room. Why? Because it's unreasonable to have to go look for something like that.
just as a curiosity-does every hospital that all of you lovely and talented nurses (and you too K) have toiled for also stock backboards in every room?
Perhaps use them as shelves to hold the Ambu bags?
Because ain't no way that 1.5 inch chest compressions at 100+ BPM are being done on a morphine induced comatose obese sleep apnic diabetic on a 10 year old hospital bed with an egg crate mattress.
Just saying...
let's move on already
this gelding has been whupped to death.
Anon,
The backboard is on the back of the crash cart, which is easily obtained on every floor...all you is pull the handy dandy alarm.
The ambu bag is super handy with that O2 connection there on the wall.
Only Michael Jackson's doc does cpr on the bed like that...
Not only do we have ambu bags in every room, but we have to throw them out when we discharge the patient even if unused (BMTU, everything gets thrown out that can't be sanitized), and we STILL manage.
"The backboard is on the back of the crash cart, which is easily obtained on every floor...all you is pull the handy dandy alarm."
Yep, right next to the ambu bag.
Just sayin
Yep - ambu bags in each & every room in my hospital as well - along with admitting, rad onc, L&D, rads, MRI (separate building) and - oddly enough - in the executive hallway (perhaps too much hot air up there).
$26/bag is small potatoes when it comes to the amount of dantrolene we haave to stock in the OR that ultimately gets discarded.
In my facility it is the Critical Care Committee which decides what is on each cart, where the carts are & what other supplies are needed & where (like ambu bags, ammonia inhalants, etc)
I hope those Nurses at the desk wrote your ass up for being a layzee self righteous incompetent wack job who is too important to help another human who is dying. I sure as shit would have.
And WTF? Fibromyalgia??
M-J "doesn't fit the profile" for an MI? You must not know what the "profile" is...
Ambubags. In. Every. Room. Not a luxury. They are cheap. Like your wifes magazines...
Im an ICU Rn at a hosital trauma, heart etc, just like Happy's hosiptal and We have ambu bags in every patient room in the entire 700+ facility, it is standard. I go on rapid calls to tele, med surg, and even the built in select long term and they all have ambu bags and suction in every room! This is has been the same for every hosiptal I have been in. Whats wrong with happy's?
Happy. . you are killing me!! Seriously? This really is standard. I work at a hospital with all the "specialty centers" just like yours. We have ambus in EVERY room! Actually they are wherever patients will be. Endo, CT, MRI, Radiology, Therapy gym, etc. In each room we also have a oximeter, manual BP, thermometer, O2 supplies such as extra tubing, nasal cannulas, venti and non rebreathers. There is also a way to call a code in each room without having to leave the patient. Each nurse carries a phone, as a matter of fact, each doc carries a phone. This is unacceptable. And of course you think your nurses are great and on top of things and are thinking them for saving your patient. That is because you couldn't do it yourself! I agree with Liz. This is pretty self rightous of you! You will never gain the respect of the nursing staff acting like this. And believe me. . you need them on your side!!! One day your arrogant attitude will come back and bite you in the ass!
haha. Wow. Zero ambu bags in 12 rooms?
That's fucking disgracful, I suggest you get on a phone and raise hell about it.
Oh wait! You don't need an ambu bag, you'd rather waste time shooting this shit with your nursing staff.
What a waste of education.
Anon (although there are about 7000 anonymous comments, but whatever...) -
Most hospital beds I've seen (ancient or otherwise) have headboards that slide off and can be slipped under the pt. to use as a backboard in an emergency. Just fyi.
~PICU RN
"'The backboard is on the back of the crash cart, which is easily obtained on every floor...all you is pull the handy dandy alarm.'
Yep, right next to the ambu bag.
Just sayin"
Airway and Breathing come before Circulation. And at Happy's hospital, those ambu bags hang out all lonely in the supply closet. What with all of that respiratory depression going on, it's still not at all unreasonable to put them in every room. After all, you can continue to bill for those patients as long as they are, you know, still alive.
Stop bustin on Happy... he trained in Grenada...
Does the stocking of ambu bags in every room vary by region of the country, size of the hospital or totally dependent on the personal preference of the person in power?
anyone out there consult at more than one hospital in an area where one hospital stocks ambu bags at the bed and another does not?
(I am a psychiatrist, I don't tend to notice ambu bags!)
What is this about Nurse K wanting your penis?
I'm on sabbatical from hospital nursing at the moment, but recently visited a friend in my local hospital. I noticed that not only were there ambu bags hanging above every bed, but there were bag-valve masks in little plastic boxes hanging liberally on walls throughout the hospital...cafeterial walls, hallways between patient rooms, in meeting rooms, in the lobby, etc., etc. Next to many of these masks in a box were hand santizing foam dispensers. I am finding it very difficult to believe that your hopsital has such a deficit of the most rudimentary of resuscitation equipment. If true, you need to get that fixed if it means yelling at the top of your lungs instead of calming going to administration and asking them what they want you to do about the problem. ~ Lou
Don't work for a national for profit hospital...if you can't get bed spreads because they cost too much to wash, ambu bags for every bed is not in the budget. You can pitch a fit till the cows come home and all it'll get you is a bad rep. We have a lonely little ambu bag hanging by the nursing stations. The stockholders are happy and and 3 of our CEO's were just nominated for the 100 most influential people in healthcare. Capitalism at work here.
That's funny...I work in an LD unit and ALL of our rooms have ambu bags (including in mother baby and prenatal rooms). We almost never have to bag an adult patient (babies are another story)...our population is typically very healthy and low risk. But we still have them.
Yup I have worked in 4 hospitals and in every facility we had an ambu bag in every room. Sorry happy , but your hospital , level 1 trauma center or otherwise, is a disgrace.
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